SSM Health St. Agnes Hospital - Fond du Lac
430 E Division St, Fond Du Lac, WI · SSM Health · · NPI 1346228541
Published prices by procedure
Cash price is what you pay without insurance. The negotiated range spans the lowest to highest rate this hospital agreed with insurers.
| Procedure | Cash price | Gross charge | Negotiated range | Payers |
|---|---|---|---|---|
| H pylori (c-13) breath CPT 83013 | $128.15 | $233.00 | $50.52 – $130.00 | 7 |
| H pylori drug admin CPT 83014 | not published | not published | $5.90 – $15.17 | 7 |
| Hrdtry brst ca-rlatd do 5+ CPT 81432 | not published | not published | $679.05 – $2,516.62 | 7 |
| Hrdtry brst ca-rlatd dsordrs CPT 81433 | not published | not published | $548.66 – $894.41 | 3 |
| Hrdtry cardmypy gene panel CPT 81439 | not published | not published | $438.68 – $1,128.86 | 7 |
| Hrdtry perph neurphy panel CPT 81448 | not published | not published | $438.68 – $1,128.86 | 7 |
| Hrv skn cll ssp agrft 1st 25 CPT 15011 | not published | not published | $1,530.61 – $3,938.76 | 4 |
| Hsv dna dir probe CPT 87528 | not published | not published | $15.04 – $38.70 | 7 |
| Htt gene charac alleles CPT 81274 | not published | not published | $206.12 – $530.42 | 7 |
| Htt gene detc abnor alleles CPT 81271 | not published | not published | $102.75 – $264.41 | 7 |
| Human epididymis protein 4 (he4) CPT 86305 | not published | not published | $15.61 – $40.16 | 7 |
| Human ig IV CPT 90283 | not published | not published | $249.05 – $249.05 | 1 |
| Human ig sc CPT 90284 | not published | not published | $62.62 – $62.62 | 1 |
| Human prothrombin complex concentrate (pcc)-lans 500 unit (400-640 unit) IV solution HCPCS J7165 | not published | not published | $1.30 – $4.90 | 5 |
| Hyaluronidase 150 unit/ml injection solution HCPCS J3470 | not published | not published | $32.56 – $81.87 | 5 |
| Hyaluronidase 200 units/ml inj HCPCS J3471 | not published | not published | $0.55 – $1.01 | 3 |
| Hyaluronidase, human recombinant 150 unit/ml injection solution HCPCS J3473 | not published | not published | $0.40 – $1.01 | 5 |
| Hydralazine 20 mg/ml injection solution HCPCS J0360 | not published | not published | $4.42 – $11.10 | 5 |
| Hydration IV infusion each additional hour CPT 96361 | $144.65 | $263.00 | $34.74 – $125.61 | 5 |
| Hydration IV infusion initial 31minutes - 1 hour CPT 96360 | $293.70 | $534.00 | $157.79 – $573.61 | 5 |
| Hydrocortisone in ns IV syringe 1 mg/ml (neo/ped) - cnr HCPCS J1720 | not published | not published | $22.64 – $57.01 | 5 |
| Hydromorphone 0.2 mg/ml in 0.9% nacl IV pca opioid naive - 4 hr dose limit (wrapper) HCPCS J1171 | not published | not published | $0.09 – $0.25 | 5 |
| Hydroxocobalamin im 10mcg HCPCS J3425 | not published | not published | $0.01 – $0.03 | 5 |
| Hydroxyzine hcl 50 mg/ml intramuscular solution HCPCS J3410 | not published | not published | $13.33 – $33.51 | 5 |
| Hydroxyzine pamoate 25 mg capsule HCPCS Q0177 | not published | not published | $5.28 – $5.28 | 1 |
| Hydrxycorticsterds 17- (17-ohcs) CPT 83491 | not published | not published | $13.42 – $34.55 | 7 |
| Hymenotomy CPT 56442 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Hymovis injection 1 mg HCPCS J7322 | not published | not published | $13.60 – $47.42 | 8 |
| Hyoid myotomy & suspension CPT 21685 | not published | not published | $4,391.52 – $11,300.84 | 6 |
| Hyoscyamine sulfate inj HCPCS J1980 | not published | not published | $24.67 – $24.67 | 1 |
| Hyperbaric oxygen therapy CPT 99183 | $1,461.90 | $2,658.00 | not published | 0 |
| #hypersens-actinomyces ab CPT 86602 | not published | not published | $7.64 – $19.65 | 7 |
| Hyperthermia ext gen deep CPT 77605 | not published | not published | $516.67 – $1,329.56 | 4 |
| Hyperthermia ext gen supfc CPT 77600 | not published | not published | $286.12 – $736.29 | 4 |
| Hyperthermia gen intrcv prb CPT 77620 | not published | not published | $409.89 – $1,054.79 | 4 |
| Hyperthermia ntrstl prb 5/< CPT 77610 | not published | not published | $409.89 – $1,054.79 | 4 |
| Hyperthermia ntrstl prb>5 CPT 77615 | not published | not published | $409.89 – $1,054.79 | 4 |
| Hypnotherapy CPT 90880 | not published | not published | $75.36 – $193.93 | 4 |
| Hyqvia 100mg immuneglobulin HCPCS J1575 | not published | not published | $13.76 – $48.16 | 8 |
| Hysterectomy/bladder repair CPT 51925 | not published | not published | $5,257.00 – $5,257.00 | 1 |
| Hysterectomy/revise vagina 58275 CPT 58275 | not published | not published | $5,257.00 – $8,770.00 | 3 |
| Hysterectomy/revise vagina 58280 CPT 58280 | not published | not published | $5,257.00 – $8,770.00 | 3 |
| Hysteroplasty 58540 CPT 58540 | not published | not published | $4,428.00 – $4,428.00 | 1 |
| Hysterorrhaphy of ruptured uterus 59350 CPT 59350 | not published | not published | $4,428.00 – $4,428.00 | 1 |
| Hysterosalpingography s&i CPT 74740 | $457.60 | $832.00 | $177.00 – $455.49 | 4 |
| Hysteroscopy ablation CPT 58563 | not published | not published | $3,710.98 – $9,549.58 | 6 |
| Hysteroscopy biopsy CPT 58558 | not published | not published | $2,401.40 – $7,791.00 | 7 |
| Hysteroscopy dx sep proc CPT 58555 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Hysteroscopy lysis CPT 58559 | not published | not published | $3,710.98 – $9,549.58 | 6 |
| Hysteroscopy remove fb CPT 58562 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Hysteroscopy remove myoma CPT 58561 | not published | not published | $3,710.98 – $9,549.58 | 6 |
| Hysteroscopy resect septum CPT 58560 | not published | not published | $3,710.98 – $9,549.58 | 6 |
| Hysterotomy abdominal 59100 CPT 59100 | not published | not published | $3,388.00 – $9,549.58 | 6 |
| I-123 iobenguane diag HCPCS A9582 | $2,691.70 | $4,894.00 | $1,738.12 – $5,648.68 | 5 |
| I-123 ioflupane diag HCPCS A9584 | not published | not published | $1,040.80 – $3,778.88 | 5 |
| I-123 sod iodide diag per 100 uci HCPCS A9516 | $64.90 | $118.00 | $303.83 – $303.83 | 1 |
| I125 iothalamate, dx HCPCS A9554 | not published | not published | $105.68 – $1,253.81 | 5 |
| I125 serum albumin, dx HCPCS A9532 | not published | not published | $351.80 – $905.29 | 5 |
| I-131 iobenguane sulf diag mibg HCPCS A9508 | not published | not published | $714.76 – $2,805.69 | 5 |
| I131 iodide cap, rx HCPCS A9517 | $50.05 | $91.00 | $18.05 – $62.96 | 5 |
| I131 iodide sol, rx HCPCS A9530 | not published | not published | $15.58 – $56.84 | 5 |
| I131 max 100uci HCPCS A9531 | not published | not published | $11.47 – $11.47 | 1 |
| I131 serum albumin, dx HCPCS A9524 | not published | not published | $981.02 – $981.02 | 1 |
| Iaadi respiratory synctial virus CPT 87280 | $29.70 | $54.00 | $10.06 – $25.90 | 7 |
| Iadna legionella pneumophila amplified probe tq CPT 87541 | $205.70 | $374.00 | $26.32 – $67.72 | 7 |
| Ia infect ag ab qual/semiquant sgl step CPT 86318 | not published | not published | $13.57 – $34.91 | 7 |
| Ia nfct ab sarscov2 covid19 CPT 86328 | not published | not published | $33.96 – $87.39 | 7 |
| Ibandronate 3 mg/3 ml intravenous syringe HCPCS J1740 | not published | not published | $24.44 – $69.04 | 5 |
| Ibmfs seq alys pnl 30 genes CPT 81441 | not published | not published | $1,836.42 – $4,725.72 | 7 |
| Ibuprofen injection HCPCS J1741 | not published | not published | $2.44 – $8.09 | 8 |
| Ibutilide fumarate 0.1 mg/ml intravenous solution HCPCS J1742 | not published | not published | $131.92 – $509.03 | 5 |
| Icatibant injection HCPCS J1744 | not published | not published | $137.85 – $367.70 | 2 |
| Icd cobalt xt dr MRI is1 df1 HCPCS C1721 | $16,159.13 | $29,380.24 | not published | 0 |
| Icd crtd cobalt hf MRI is1 df1 HCPCS C1882 | $21,728.44 | $39,506.25 | not published | 0 |
| Icd crtp serena MRI HCPCS C2621 | $9,933.00 | $18,060.00 | not published | 0 |
| Icg angiography i&r uni/bi CPT 92240 | not published | not published | $160.18 – $412.19 | 4 |
| Icut allergy test-delayed CPT 95028 | not published | not published | $27.71 – $71.30 | 4 |
| Icut allergy test drug/bug CPT 95024 | not published | not published | $43.76 – $112.62 | 4 |
| Icut allergy titrate-airborn CPT 95027 | not published | not published | $21.46 – $55.21 | 4 |
| I&d abscess posterior spine l/s/ls-22015 CPT 22015 | not published | not published | $3,388.00 – $18,364.00 | 6 |
| I&d abscss rtrphryngl/paraphryngl intraorl apprch CPT 42720 | not published | not published | $2,459.51 – $6,329.15 | 6 |
| Idarubicin hcl injection HCPCS J9211 | not published | not published | $47.86 – $127.41 | 5 |
| I&d/bursa/foot 28001 CPT 28001 | not published | not published | $1,225.21 – $4,761.00 | 6 |
| Idecabtagene vicleucel car HCPCS Q2055 | not published | not published | $425,983.34 – $1,438,330.59 | 7 |
| Identify sperm tissue CPT 89264 | not published | not published | $38.66 – $99.48 | 5 |
| Idet 1 or more levels CPT 22527 | not published | not published | $3,735.00 – $8,770.00 | 3 |
| Idet single level CPT 22526 | not published | not published | $3,735.00 – $8,770.00 | 3 |
| I&d frarm&/wrst deep absc/hematoma CPT 25028 | not published | not published | $2,427.27 – $7,791.00 | 6 |
| Idh1 common variants CPT 81120 | $496.10 | $902.00 | $144.94 – $372.97 | 7 |
| Idh2 common variants CPT 81121 | $786.50 | $1,430.00 | $221.84 – $570.87 | 7 |
| I&d intramural/intramuscular/submuc abscess transanal anes CPT 46045 | not published | not published | $2,059.07 – $7,791.00 | 6 |
| I&d lacrimal gland CPT 68400 | not published | not published | $739.52 – $4,761.00 | 6 |
| I&d lacrimal sac CPT 68420 | not published | not published | $1,763.69 – $4,538.57 | 6 |
| I&d upper arm/elbow deep abscess/hematoma CPT 23930 | $2,014.65 | $3,663.00 | $2,154.81 – $7,791.00 | 6 |
| Idursulfase injection HCPCS J1743 | not published | not published | $427.53 – $1,476.19 | 8 |
| I & d vag hematoma non-ob 57023 CPT 57023 | not published | not published | $2,154.81 – $7,791.00 | 6 |
| I&d vag hemtma obst/postpart CPT 57022 | not published | not published | $2,154.81 – $5,545.05 | 6 |
| Ifnl3 gene CPT 81283 | not published | not published | $55.03 – $141.60 | 7 |
| Ifosfamide 1 gram intravenous solution HCPCS J9208 | not published | not published | $27.08 – $68.26 | 5 |
| Igh@/bcl2 translocation alys CPT 81278 | not published | not published | $155.48 – $400.11 | 7 |
A missing value means the hospital did not publish that price — it never means the price is zero. Real bills can add facility fees, supplies and professional fees; see our methodology.